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Fang Xuanling presented with smallpox lesions that were black in color, the size of a longan fruit. An old monk saw this and exclaimed, "This is the noble appearance of 'ten thousand dragons holding pearls'; I have seen it only now."

Qiu Qiongshan, at seven years old, also had smallpox lesions covering his entire body that turned black. His father was worried and wept bitterly. A fisherman examined him by candlelight and joyfully said, "The stars Fu (Assistant) and Bi (Minister) from the Purple Forbidden Enclosure have fallen into this humble farmer's family." He took a brush, wrote the characters "Fu" and "Bi" on the child's back, and then left.

In the past, there was a child whose smallpox lesions were all black in shape. When viewed in sunlight, they appeared black; but when illuminated by a lamp, a true red color could be seen shining from within. He accidentally met a monk who did not administer internal medicine but instead bathed him with Baoyuan Tang (Preserve the Origin Decoction). The lesions immediately turned red and vibrant. Later, this child attained the high official position of Taifu (Grand Tutor/Chancellor).

There is a type of black smallpox where the lesions are round, complete, and glossy. By the time pus forms, the color resembles purple grapes, and the blood halo around the base of the lesion is slightly yellow. This manifestation is named "Purple Robe with Golden Belt."

Wan Mizhai treated the son of the Wang family for smallpox. During the eruption stage, the lesions gradually turned black and spread over the entire body. Someone remarked, "When smallpox turns black, it indicates involvement of the Kidney and is incurable." Wan Mizhai said, "There are two types of black smallpox syndromes. One is dry and shriveled turning black, known as 'inverted collapse' (Dao Xian), caused by extreme blazing of pathogenic fire and exhaustion of true yin fluids; thus, it is said to involve the Kidney and be incurable. The other is where the lesion color turns black but does not become dry or collapsed; this is due to epidemic toxic qi, described as 'fire erupting and causing obscuration.' This case precisely belongs to the latter category. Therefore, he used Danggui Shao (Radix Angelicae Sinensis Cauda), Shengdi (Radix Rehmanniae Preparata), Chishao (Radix Paeoniae Rubra), and Honghua (Flos Carthami) to cool the blood; Huangqi (Radix Astragali), Renshen (Radix Ginseng), and Gancao (Radix Glycyrrhizae) to clear fire and tonify primordial qi; Jiu Chao Huangqin (Scutellariae Radix fried with wine), Jiu Chao Huanglian (Coptidis Rhizoma fried with wine), Niubangzi (Fructus Arctii), Lianqiao (Fructus Forsythiae), and Shengma (Rhizoma Cimicifugae) to resolve toxicity; Jingjie (Herba Schizonepetae) and Fangfeng (Radix Saposhnikoviae) to disperse the exterior. To each dose, one qian of burned human feces was added. After administering thirteen doses continuously, the color turned red, pus formed, and scabs developed.

The son of the Li family presented with smallpox lesions that turned black and dry during the eruption stage, accompanied by fever and no bowel movement since the onset of fever. Wan Mizhai said, "The heat is severe internally; it must be resolved urgently." He prepared a formula: Mahuang (Ephedrae Herba) stir-fried black with honey, Honghuazi (Semen Carthami), Zicao (Radix Lithospermi), Renzhonghuang (Nitrified Human Excrement), Lianqiao (Fructus Forsythiae), Jiuzheng Dahuang (Rhei Radix et Rhizoma steamed with wine), and burned human feces, decocted and administered orally. Externally, he employed the Dan Dao method (pig bile enema) to expel dry stool. After the dry stool was passed, the lesions turned red and vibrant. Subsequently, Siwu Tang (Four Substance Decoction) without Chuanxiong (Rhizoma Chuanxiong) was modified with the addition of Zicao (Radix Lithospermi), Mutong (Caulis Akebiae), Zhike (Fructus Aurantii), and Sheng Gancao (Raw Radix Glycyrrhizae) for regulation, leading to recovery.

Black smallpox is mostly caused by Ding Du (carbuncle toxin). Including these cases in this section is to prevent people from misidentifying the condition.

The son of the Xu family, aged thirteen, had smallpox lesions that had formed pus and were about to scab. Someone remarked, "If the lesions turn black, it involves the Kidney and is incurable." Upon examination, the lesions were distinct and prominent, the pus was full, the spirit was clear, and speech was crisp and loud. Only the bowel movement had been absent for five days. This indicated excess heat steaming internally, causing ulceration; the dark black color was actually the normal color in this context. Resolving the internal excess would lead to scabbing. One dose of Sishun Qingliang Yin (Four-Compliant Cooling and Clearing Decoction) was given, resulting in the passage of more than twenty pieces of dry stool. He subsequently scabbed and recovered safely.